Professional Nursing PrepU

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results?

Graphic sheet

The nurse formulates for a client the nursing diagnosis of: Impaired Mobility related to postoperative pain as evidenced by difficulty ambulating. Which component of this nursing diagnosis is the descriptor?

Impaired

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

Impaired low nutritional intake

The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis will the nurse prioritize?

Impaired skin integrity

The nurse is admitting a client who is unable to identify person, place, or time. To properly analyze these data, what action must the nurse take?

Interview the client's family to assess the client's usual level of cognition

Verbs to be avoided when writing goals

Know, understand, learn, become aware

All of the activities listed are related to evaluation, but which evaluation activity is the priority concern for nurses?

Measuring client outcome achievements with the client

The nurse is assessing a client in the community. To obtain a relative estimate of the client's skeletal mass, the nurse will take which measurement?

Midarm circumference

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

Which is most important for the nurse to include in a client's plan of care?

Nursing interventions

The nurse is preparing to call a health care provider to report a significant decrease in a client's oxygen saturation level. What action should the nurse take first?

Obtain all needed information to give report

Quality assurance focuses on...

Organization structure and individuals and is externally driven

A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client?

Possible

Which action should the nurse perform during the planning step of the nursing process?

Selects nursing measures, including client education

A catastrophic event with a client that can cause loss of life or limb or other serious injury to the client

Sentinel event

Quality assurance programs focus on three types of evaluation

Structure, process, outcome

Which components should the nurse include when documenting a critical pathway?

Timeline, expected outcomes, care plan

When creating a care plan, which is the purpose of identifying the client outcome?

To design a plan of care to address the health problem

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records"

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it"

The following documentation errors may potentially increase the nurse's risk for legal problems...

-The content is not in accordance with professional standards -There are lines between the entries -Dates and times of entries are omitted

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?

A plan designed to support the client physically

A client who recently became quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select?

A syndrome nursing diagnosis

The process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency

Accreditation

The nursing diagnosis is the identification of a client ________ or problem, not a need

Alteration

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

Assess the client's interactions with the newborn

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate?

Assess the triggers from the data

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

An evaluation of care that has been performed and documentation that has been made

Audit

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Charting by exception

Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use?

Clinical pathway

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention?

Coordinating

Focus charting

DAR (data, action, report)

A nurse is reviewing a client's plan of care. What would the nurse determine is a problem related to the assessment phase of the nursing process?

Database does not reflect changes in the client condition

Actual nursing diagnosis components

Diagnostic label, related factors, defining characteristics

Significant deviations are important when using charting by...

Exception

Which charting format permits documentation on any significant topic, not just client problems?

FOCUS

It gives priority attention to the client's current or changed behavior

FOCUS charting

Parts of problem focused nursing diagnosis

-Name of health related issue or problem -Etiology -Defining characteristics (S&S)

While caring for a client admitted to the hospital for a fractured tibia, the nurse notes the client's blood pressure readings are consistently higher the expected range for the client's age. How would the nurse most appropriately plan to care for this client?

Address the collaborative problem PC: Hypertension

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the healthcare provider

Which nursing interventions are appropriate to perform when addressing a risk nursing diagnosis?

Prevent the problem Reduce or eliminate risk factors Monitor the client's status

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and...

Reimbursement

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting S&S related to the client's kidney failure

Which action is a priority role of the nurse when caring for a client with collaborative problems?

Reporting trends that suggest the development of complications

Which error has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly?

Used legally inadvisable terms

Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence?

Yes, this defines a possible nursing diagnosis

Which is the priority question for the nurse to consider before implementing a new intervention?

Does this treatment make sense for this client?

The nurse manager is holding a staff meeting and indicates that the unit is looking at a 3% budget cut for the coming year. The nurse manager asks the staff what they see as priorities for the unit, and solicits suggestions from the staff as to what budget areas might be reduced. Which standard for establishing and sustaining healthy work environments does this action represent?

Effective decision making

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?

"The care plan is required for every client by The Joint Commission"

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved?

-Analyzing data -Identifying patterns -Identifying indicators of potential dysfunction

Which information should the nurse include in a client's plan of care?

-Client's problems, goals, and nursing orders -Routine care -Level of activity -Current medical orders

Process of performance improvement

-Discover a problem -Plan a strategy -Implement a change -Assess whether change was effective

What does outcome include?

-Subject -Verb -Time frame -Performance criteria -Circumstances by which outcome is achieved

The definition of Domain 1 nursing diagnoses is...

-The awareness of well-being or normality of function -The strategies used to maintain control of and enhance that well-being or normality of function -Ineffective Health Management -Sedentary Lifestyle -Decreased Diversional Activity Engagement

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?

A risk nursing diagnosis

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?

A variance

Standing orders and protocols often surround the management of...

Bowel elimination

Are also called critical pathways or care maps

Collaborative pathways

Which is the primary purpose of client records?

Communication

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's...

Condition

The nurse has identified a client's most significant nursing diagnosis. The nurse will base the diagnosis on which foundational element?

Cues

Risk nursing diagnosis components

Diagnostic statement (the risk) and risk factors; use "related to"

After a client has a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." To determine the accuracy of the diagnosis, what would be the nurse's most appropriate action?

Discuss the client's health condition with the client

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns

Related factor is also known as the...

Etiology

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain?

Implement the ABC guide of pain management

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis?

Ineffective Airway Clearance

Which nursing action would be most effective in helping a client learn self-care behaviors?

Model self-care behaviors for the client

An error that occurred that should not have

Never event

A large university hospital has commissioned a multidisciplinary group to review client records following discharge to evaluate client outcomes and the character and quality of nursing care that clients receive. Which type of evaluation process will take place?

Nursing audit (evaluating nursing care that involves reviewing client records to assess the outcomes of nursing care)

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of...

Outcome evaluation

PIE charting is a method of recording the client's progress under the headings of...

Problem, intervention, evaluation

The nursing supervisor is presenting the staff nurses with annual performance evaluations. What type of evaluation is the supervisor presenting to the staff?

Process

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this as which type of evaluation?

Process evaluation

Quality improvement focuses on...

Processes, data, statistical thinking, client satisfaction, and promotes empowerment/collaboration

When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings?

Refer to the health care provider

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as...

Related factors

Which action should the nurse take when client data indicate that the stated goals have not been achieved?

Review each preceding step of the nursing process

The client reports right knee pain of 6/10 on the 10-point pain scale and requests medication. The nurse assesses and flushes the intravenous site before administering IV analgesia. Which type of intervention skill is the nurse using?

Technical skill

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

The Joint Commission (TJC)

The nurse is reviewing a client's chart. When reading the history, physical, and health care provider progress notes, the nurse anticipates finding which information?

The health care provider's assessment and treatment

Which characteristic is the most important indicator of high-quality nursing practice?

The nurse considers the individual needs of clients

A client who gave birth yesterday refuses to eat the food provided by the hospital. The client reports needing special food brought from home by family. How would the nurse most appropriately address this situation?

The nurse should not formulate a nursing diagnosis but should encourage the client to have family bring food from home

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

Those directly involved in the client's care

The nurse is performing evaluation as part of enacting a client's nursing care plan. Which purpose of this phase of the nursing process will the nurse prioritize?

To examine the client's behavioral response to the care received

The nurse is developing and documenting a nursing diagnosis for a client. When formulating the nursing diagnosis, what guidelines should the nurse follow?

Use accepted terms for the specific facility

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section

The nurse has established client outcomes and outcome criteria. What should the nurse do next?

Write a plan of care

A client whose care plan includes a nursing diagnosis of "Risk for Infection related to a disruption of skin integrity secondary to abdominal surgery" is displaying redness, edema, and warmth at the surgical site. What would be the nurse's most appropriate revision of the care plan?

PC: Infection related to disrupted skin integrity secondary to abdominal surgery

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?

Report the findings to the health care provider for further plans

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information?

The agency's critical path

The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The health care provider asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent?

True collaboration

A nurse is working with the case management model and using a collaborative pathway. The nurse notes that the client has not met an expected outcome and documents this using occurrence charting. When completing this documentation, what information would the nurse include?

Unexpected event, cause of the event, actions take in response to event

A nurse has begun a new role on a high acuity unit where clients' health status often change rapidly. What practice should the nurse adopt to maximize the accuracy of documentation?

Use point-of-care documentation whenever possible

The nurse has systematically gathered and clustered data to draw inferences regarding a newly admitted client's health problems. The nurse has then selected a nursing diagnosis. What will the nurse do next?

Validate diagnosis with patient

Which action should the nurse perform in the evaluation phase?

Revise the plan of care

The nurse has assessed a client and drafted a nursing diagnosis that is outside the nurse's scope of practice. Which is the nurse's most appropriate action?

Revise the diagnosis so it is in the nurse's scope of practice